The Minimum Data Set: Abstraction Tool for Standardized, Comparable, Essential Data

Hamet H. Werley, RN, PhD, Elizabeth C. Devine, RN, PhD, Cecilia R. Zom, RN, MSN, Polly Ryan, RN, MSN, and Bonnie L. Westra, RN, MSN Inrducdion is a system that can be used by public health nurses in theirpractice and for com- With the rapid explosion of nursing parison of nursing care and resource con- knowledge worldwide, the amount ofdata sumption across other settings, thus pro- nurses use and process in the delivery of viding linkage to all other nursing care care is extensive and often unmanageable. settings. Advances in information management In addition to providing a mechanism and computer technology have broad im- for the comparison of nursing care data plications for this knowledge explosion across settings, the Nursing Minimum and can facilitate the collection, manipu- Data Set can be combined with the more lation, and retrieval of essential nursing detailed data accumulated in nursing in- data for practice and research. A uniform formation systems and other standardized data base that will allow for information systems. In the future, it is the grouping and comparison of nursing anticipated that these nursing information across various data collected populations, will be both and in settings, geographic locations, and time systems computerized existence at the institutional level, would be a boon to both assessing and where, comparing nursing care provided and re- through data-base management systems, sources used, as well as to research. Eli the nursing data can be linked to other Ginzberg,1 in reviewing nursing's past and health data. In this way, the use of the present, noted that nurses still are writing NMDS in detecting trends in nursing care patient records for two to three hours out practices and resource allocation is ex- of every eight-hour shift; he predicted the panded further. necessity for reviewing essential record- The Nursing Minimum Data Set is keeping and of greater use of computer- nursing's first attempt to standardize the ization in nursing. collection of essential, comparable core Public health nurses identified the nursing data. In this paper we discuss need to explore minimum data set require- briefly: background, including definition, ments for their practice and planned to purposes, and elements of the NMDS; prepare a miniproject proposal to accom- availability and reliability ofthe data; ben- plish this.2 However, as this project was efits; implications with emphasis on nurs- descnrbed, the data acquired in a public ing research; and health policy decision health setting apparently could not be making. linkedwith those from other areas ofnurs- ingpractice. Thiswould continue the frag- mentation of documentation on nursing From the School ofNursing, UniversityofWis- care of patients. As nurses in public consin-Milwaukee. Address reprint requests to health, and in other practice areas, con- Harriet H. Werley, RN, PhD, Distinguished tinue to discuss the necessity and value of Professor, School of Nursing, University of a minimum data set, itis essential that they Wisconsin, Milwaukee, WI 53201. This paper, submitted to the Journal August 25, 1989, was recognize that the Nursing Minirnum Data revised and accepted for publication June 30, Set (NMDS), along with its elements and 1990. definitions, constitutes a minimum set of Editor's Note: See also related editorial p 413 nursing's essential core data.3 The NMDS this issue.

American Journal of Public Health 421 Werky, et al.

toward submission of proposals to de- velop nursing information systems. In ad- dition, one of the small work groups was given the challenge of identifying a basic nursing data set. Their effort9 is shown in Figure 1. However, the timing for move- ment in this direction apparently was not NIS right for nursing at that time. One of the authors (HHW) opened the subject again a fewyears later. In 1985, Community a NMDS Conference was developed at Data the University of Wisconsin-Milwaukee School of Nursing. The NMDS was de- Resources, veloped consensually through the efforts Health Problems, ofa national group of64 experts, who par- Socioeconomic ticipated in this three-day invitational con- -cultural status ference. The participants included: nurse Aggregate data on experts in a variety of areas; health policy population at risk spokespersons; information systems, health data, and health records specialists; Institutional Data governmental and proprietary agency per- Personnel Structural Finance sonnel; and persons knowledgeable about Variables the development ofthe previous niinimum Interpersonal Data health data sets.3,10,11 Nursing NMDS Definition Intervenitions & Goal Medical Orders (Outcome) Built on the concept ofUniform Min- imum Health Data Sets, the NMDS is de- Patient Data fined as a minimum set of items of infor- Demographic Physiological & Medical & Patient's mation with uniform definitions and Character Psychosocial Nursing Perception categories concerning the specific dimen- factors Diagonosis & Goal sion of nursing which meets the informa- tion needs of multiple data users in the NURSES' SCIENTIFIC KNOWLEDGE 1 health care system. It includes those spe- cific items of information that are used on FIGURE 1-Categories of a Basic Nursing Data Set a regular basis by the majority ofnurses in NOTE: Adapted from Nursing Information Systems by H. H. Werley and M. R. Grer (eds). any care delivery setting. It is an abstrac- NewYork: Springer Publishing, 1981; 282. Copyright 1981 by Springer Publishing Company, tion system, or tool, designed for the col- Inc, New York 10012. Used by permission. lection of uniform, standard, comparable, minimum nursing data for use across var- ious types of settings and patient groups. Background pital Discharge Data Set is the only min- These data also are useful to other health imum health data set in widespread use professionals and researchers. The NMDS was derived from the currently, since these data must be col- general concept of a Uniform Minimum lected on all hospitalized patients receiv- Purposes ofthe NMDS Health Data Set, defined as "a niinimum ing Medicare benefits; it does not include set of items [or elements] of information The purposes of the NMDS are to: nursingdata, however. The NMDS is con- * establish comparability of nursing with uniform definitions and categories, sistent with but expands the Hospital Dis- or dimension data across clinical populations, settings, concerning a specific aspect charge Data Set by including core nursing ofthe health care system, which meets the geographic areas, and time; essential needs of multiple data users."4 data. The Long-Term Health Care Mini- * describe the nursing care ofclients Note the emphasis on multiple users and mum Data Set and the Ambulatory Care and their families in a variety of settings; not only a specific group of users; a min- Minimum Data Set currently are being re- * demonstrate or project trends re- imum set of items of information in nurs- vised and tested. garding nursing care provided and alloca- ing must meet the needs of other data us- The NMDS effort is a follow-through tion of nursing resources to individuals or ers as well as nurses. on earlier work that was done at the Uni- populations according to their health Existing patient-focused health data versity of Illinois. In a Nursing Informa- problems, or nursing diagnoses; sets built on this concept include: the Uni- tion Systems Conference held in 1977 at * stimulate using form Hospital Discharge Data Set, the the University of Illinois College of Nurs- the NMDS elements alone, as well as Long-Term Health Care Minimum Data ing in Chicago,8 an effort was made to through links to the more detailed data Set, and the Uniform Ambulatory Medi- stimulate nurses to move toward comput- existing in nursing and other health care cal Care Minimum Data Set.5-7 The Hos- erization of nursing services data and information systems;" and

422 American Journal of Public Health Aprfl 1991, Vol. 81, No. 4 NMDS, Abstraction Tool for Standardized Data

The nursing care elements consist of Interventions (which were included for pi- , Nursing Intervention, lot testing only), was a satisfactory 91 per- Nursing Outcome, and Intensity of Nurs- cent, with an item-specific range of57 per- ing Care (with its two subelements of cent to 100 percent. For categorical-tpe Hours of Care and Staff Mix).3 Unfortu- data with fewer than 10 possible coding nately no single classification system for categories, coefficient Kappa was calcu- t::t2: .'.'..!..'.'!''..'!"'~~ ~~~~~~ '"'.'.'';''"''.'.''.''...... " '' '!'"!t''''t' nursing diagnoses is widely and univer- lated,19 with similar results. The implica- sally accepted. Currently, two well-recog- tion of these results is that the definitions :|"":S f:: :-,...X.-.. ..-...-.} - - ...... }::.-.- ...-.... :'.':-..>:.....:..}e. nized classification systems are available: and protocol for coding were generally ac- the North American Nursing Diagnosis ceptable, although a few elements needed g.":,: .":,:, : .f S f i ; ~~~~~~...::...... ::..... :: :'''S S "S5 5: Association Taxonomy I Revised13 and refinement, which has been done.17

f' ""'g"S5'S':'..'.s""|"'' :':~f'S' SS fef e ...,....S':'.'.'' the Classification Scheme for Client Prob- -:s.-.s.-..rS.s.s..mS.-~~~~~~~~~~.....r.S..: ._s s.... lems in Community Health Nursing from Benefit ofthe NADS Th|! NMDSincludesS >..,,,,,.'!e:f ,16,.,items or el Omaha14 (hereafter referred to as the Omaha Classification System). Both have The benefits for nursing, if the been examined in community health set- NMDS were adopted nationwide in ongo- IEpec:t.d:Paetor Mas o->>---h>- tings. For example, in a retrospective ing data collection systems, include: chart review study, Mundt15 noted the * Access to comparable, minimum compatibility of information documented nursing care and resources data on local, in narrative charting by nurses in a mid- regional, national, and international lev- westem urban public health department els; :-..:e,.f ,-S:.-.::f.:.-f.:.-:...: :,.. S. S.: f :i : S S " -'..:f.S::g.ss s .s;-5 y --~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.-.'..S'."'-''-.'...5 fexe ...-. S : .U.'.S....f...... 'S'f''''::::'''::. S'':":'S'"S. .. with the Omaha Classification System. * Enhanced documentation of nurs- Likewise, Hemphill, Lutes, Taylor, Car- ing care provided; roll, and Cragg16 integrated the North * Identification of trends related to American Nursing Diagnosis Association client problems or nursing diagnoses and NMDS are components of the Um .or classification system of nursing diagnoses nursing care provided; into the documentation system of a large * Impetus to improved costing of ementS,''''Sff that:f':t>S,hav been caeonemffSfSSSfSsSS western county public health department, nursing services; showing that their documentation became * Improved data for quality assur- shown..""..'in, Table 1. Ten elmetote,,f.5,,.,,fthe more clear and concise. To accommodate ance evaluations; Hos pita vis rea aabouta nsingta 'atletS the diversity in classification systems for * Impetus to further development itemsi --f--fsSbefinarecollected5an facit fo se.Whall'hospitalizedhealthincdecipa nursing diagnoses, the authors of the andrefinement ofnursing information sys- tient--g|fis reeiin Medicar beeft Six''S' ''-Nursing Minimum Data Set (NMDS) tems; Data Collection Manuall7 suggested cod- * Comparative research on nursing ing both the classification systems used care, including research on nursing diag- and the actual diagnoses. While this does noses, nursing interventions, resolution not assure exact comparability of data, it status ofclient diagnoses orproblems, and does allow data to be collected from more referral for further nursing services; settings. Until a single classification sys- * Contributions toward advancing fiormationgssesar opteie n tem for nursing diagnoses is accepted nursing as a research-based discipline; ient Ti Tastem linkag ewth t fUrn lNkeDSars differettpetfsetns more widely, nursing diagnosis data can and, be aggregated across settings only when * Easily retrievable data that would onyThe NDinewde1items,wudnetorbelre using the same nursing diagnosis classifi- make nursing's data available for nursing, vacolectedluabl nolctefortfolhosialiebeeb au ofMdcatgriedthe-ita formareip cation system. as well as for other health care providers throieNMDStanenanctnrsnaethemngmn and policy makers. portemant aswthetkeystot ent oherdatai It is important to recognize and value fomHospital Discharge Data Setistaled Availability and Reliability of these benefits, since nurses have been Data slow to work toward developing and com- tionths datavinseticnains butefmore Sim puterizing nursing information systems In a test of the NMDS, data were with ongoing collection of nursing's es- sermts," "t almos collected pertaining to the availability and sential core data. sucystacess cobptarinzan reliability of the NMDS elements from a ompletehitrenofthemtotald peridtofhosre review of 116 client health care records Impiatons ofthw NMDS pitalezationfor aosvaraizetyo uses."12eUseiof from four types ofclinical sites in the mid- west: a hospital, a nursing home, a home Implementation ofthe NMDS has far theuaNeMDS canl benhance ofthemanagement health care agency, and two clinics affil- reaching implications for health policy de- tof hidata-o only winthinshospitalsbut iated with a teaching hospital.18 Most of cision making and for nurses in the respec- alt,"souchsstions.za sesnsS: inof vbariou longo," -2t f '' terms-e f the NMDS elements were available for tive functional areas of nursing in the loaos greater than 90 percent ofthe cases. Over- health care delivery system. carpetan pubictr healthe geogralphrical all intercoder agreement on the data set elements, excluding the Unique Number Clinical Practice and Administration of Principal Provider Relatively recently, the Committee (which was never available) and Nursing for the Study of The Future of Public

April 1991, Vol. 81, No. 4 American Journal of Public Health 423 Werley, et al.

Health2-0 stressed greatly the need for pro- cause of the need for implementation of nomena pertaining to patient care, nursing fessionals to maximize the influence ofac- the NMDS as an abstraction tool for col- research, nursing education, and nursing curate data and professional judgment on lection of standardized, comparable data. administration."2A Consideration of these decision making. The Committee recom- two components-consistent documenta- mended "that every public health agency Research tion and a unified language-will assist regularly and systematically collect, as- Use of the NMDS results in a com- nurses in moving more rapidly toward semble, and make available information pilation of nursing information across computerization ofnursing services' data. on the health ofthe community, including populations, settings, geographical loca- In an effort to avoid the problem of statistics on health status, community tions, and time, using the same elements inconsistency in the matter of coding, a health needs, and epidemiologic and other and definitions, labels, NMDS Data Collection Manual has been studies ofhealth problems." As the Study and categorizations. If nurses are to de- developed.17 The Manual includes: the Group on Nursing Information Systems21 scribe, compare, and assess their practice, NMDS data elements and definitions; a stated, at the 1982 Cleveland, Ohio Con- they must be able to communicate with description of how to organize and con- ference, "Management and practice data each other using comparable data. Re- duct a survey of agency health care rec- are interrelated or complementary and cently, Trevino noted that "all too often ords for the purpose ofextracting and cod- should be so perceived; ultimately, both the utility of potential information re- ing information; four setting-specific kinds of information could be obtained sources is [diminished significantly] be- versions of the instrument, as well as, in- from the same data." Both public health cause of a lack of comparability in the structions for data collection, analysis, nurses and nurse administrators have re- definitions, codes, classifications, termi- and interpretation. sponsibility for the implementation of the nology, and sampling frames used by dif- NMDS elements. Public health nurses and ferent agencies at the federal, state, and Types ofResearch Possible with the nurse clinicians should stress complete, local levels."22 He identified several con- NMDS Elements accurate documentation of nursing care sequences of this lack of comparability, Examples of research that could be according to the nursing process. Conti- which included: difficulty inmakingmean- done using the NMDS elements to en- nuity of care provided to clients trans- ingful comparisons, increased cost in col- hance nursing practice, include: ferred among health care settings can be lecting new data in an attempt to make up * the description of nursing care of facilitated through proper and accurate for inconsistencies, and major gaps in data clients in various settings; documentation ofcare. Nurse administra- where much information still is lacking. * evaluation of the resolution status tors should highlight both the need to ab- Westermeyer also discussed con- of nursing diagnoses and referrals for fur- stract core, minirmum nursing data in pub- cerns about the lack of comparable data ther nursing care; lic health agencies and the need for these when he was developing a strategy for an * assessment of patterns of out- data to be comparable across the various alcoholism social indicator system, using comes for various nursing diagnoses with types ofcare delivery settings, so that they information already collected by various different populations; and can be incorporated into further develop- institutions. After reviewing data col- * comparison of nursing interven- ment ofcomputerized nursing information lected from five state agencies, two na- tion effectiveness for specific nursing di- systems. Furthermore, nurse administra- tional private agencies, and two federal agnoses across settings-locally, region- tors should recognize the trends these agencies, he concluded that age and gen- ally, nationaLly, and intemationally. core data can reflect about both public der were the only two variables that were Research for nursing administration health nursing practice and the resources collected routinely and therefore were might include: used in providing services, as well as the available for comparison of data across * evaluation of the procedure for research possibilities of these data. agencies. Westermeyer further stated, costing nursing care for selected nursing "Failure to develop social indicators will diagnoses in a variety of population Education impede the evolution ofenlightened social groups; Nurse educators must create an policy and research into the factors asso- * appraisal of the cost-effectiveness awareness in students of the necessity to ciated with health problems."23 The of nurse staffing pattems and their impact document care appropriately, reflecting NMDS includes not only social indicators on the resolution status of nursing diag- use ofthe nursing process. Faculty should that must be comparable with other data noses; be held accountable for ensuring the inte- bases, as suggested by Westermeyer, but * evaluation of the pattems of nurs- gration of information management and also nursing's essential core elements that ing care and resource requirements in the computerization in the undergraduate and must be comparable and of use in other different types of care delivery settings- graduate curricula for use in decision mak- data bases, in order for nursing to conduct hospitals, nursing homes, home health ing in all areas of nursing. Furthermore, certain types of research across popula- care agencies, and ambulatory clinics; as nurse educators in undergraduate and tions, settings, and geographical loca- well as graduate programs should stress the rele- tions. * analysis of existing and emerging vance of the NMDS as an integral com- Equally as important as consistent resource allocation methodologies for ponent of nursing information systems. documentation in its implications for the nursing services. Continuing education for public health development of computerized nursing in- nurses and clinicians should include basic formation systems is the need for a unified Health Policy Decision Making information regarding the NMDS ele- language in nursing. As pointed out by Public health nurses, like nurses gen- ments, their definitions, benefits, and im- McCormick, "A major impediment to erally, must have data that reflect their plications. The importance ofcareful doc- more wide spread use of computers in practice, in order to influence health pol- umentation of care provided and nursinghasbeen the absence ofa standard icy development. Two issues illustrating resources used should be stressed, be- vocabulary for describing health care phe- this need for nursing data are prospective

424 American Journal of Public Health Aprd 1991, Vol. 81, No. 4 NMDS, Abstraction Tool for Standardized Data payment for home health care and the ef- role in health care, it must have standard- For too long, nurses have attempted to fectiveness initiative.25 26 It has not yet ized data and must demonstrate its essen- define nursing and evaluate the effective- been determined ifthere will be a prospec- tial nature and effectiveness. A national ness ofnursing interventions with the con- tive payment system for home health care. health care data base is being developed cepts essential to the epidemiology of However, if one is developed, the kind of which will provide a basis for making medical practice. Nurses are interested in data used to determine payment must be many decisions. Nurses must become the responses of clients to actual and po- readily available and retrievable, and this aware of the urgency of having nursing's tential problems, involving health mainte- means computerization. Medical diag- information systems developed and com- nance and the prevention of illness. Nurs- noses are the most frequent method ofcat- puterized, so nursing data can be included ing's language, represented by the NMDS egorizing client problems, but these do not in the broader data base development for elements and definitions, incorporates the reflect thevariance in the costofcaringfor studies of effectiveness and dissemination broad scope ofinformation used bypublic clients in the home. Rather, home care of findings. Nursing data also must be health nurses. clients have nursing problems and require readily retrievable and available for health Because of requests from nursing nursing care; a major service provided for policy making as health policy issues are professionals and others, information home care clients is nursing care. If nurs- raised. about the NMDS and its relationship to ing data were collected routinely using the Aside from uses already mentioned, the development of nursing information NMDS elements (in particular, nursing di- implementation of the NMDS in public systems is disseminated at both nationaP29 agnoses, interventions, and outcomes, health nursing would provide nurses with and international3O meetings. But a word and intensity of nursing care), nursing in- a large data base to describe the popula- of caution is necessary for individuals de- formation would be available for develop- tion, nursing practice, and allocation of veloping computerized nursing informa- ment of a prospective payment system resources. The frequency ofnursing prob- tion systems. Through talkingwith nurses that is likely to account for more variance lems or diagnoses, the outcomes for about their information systems, it is ap- in the cost of providing care to clients in groups ofindividuals, and the amount and parent that simply entering the nursing the home setting. intensity of nursing care provided for data into an integrated computerized in- The second health policy issue for those groups of clients could be articu- formation system may not be enough. The which the NMDS is essential is the Med- lated. Additionally, the association be- nursing data also must be retrievable in ical Treatment Effectiveness Program.26 tween and among diagnoses, interven- order to be put to any meaningful use. This is a federally funded program de- tions, outcomes, and intensity of nursing That is, the subset of nursing's data must signed to demonstrate which procedures care (as measured by the two subele- be retrievable from the overall client or or interventions are the most effective in ments: Hours ofCare and StaffMix) could public health information system, so the producing quality client outcomes. With- be identified. The data set would assist data elements can be examined by nurses. out access to a standardized nursing lan- nurses to explain and predict trends in If nurses cannot be shown what nursing guage, effectiveness of nursing care can- their practice, providing them with aggre- data are retrievable, these data may have not be demonstrated. One component of gate data rather than only anecdotal ac- been integrated into larger information the effectiveness initiative program is the counts of practice. systems and then deleted without letting development of data bases that can be Use ofthe NMDS would enable pub- nurses know of this deletion. Nurses linked to Medicare files and other popu- lic health nurses to plan and evaluate care. must, as autonomous professionals, be lation data bases that may lead to im- With reflected changes in data trends knowledgeable not only about entering proved quality ofclient outcomes. Today, within this database, nurses could plan for data, but also about retrieving them, in nursing's data are absent from current the health needs of the future. By review- order to assure the integrity of nursing's data bases. Implementation of the NMDS ing the information available through the essential data. There are ways of keying would demonstrate the effectiveness of NMDS system, they would be able to de- nursing data so they can be retrieved. This care provided by nurses, including those tect how their client groups have changed was discussed recently in a monograph in . over time with respect to demographics, developed for the American Nurses' As- Public Health Nursing may be at a diagnoses, interventions, and outcomes. sociation (ANA) Council on Computer crossroads. If public health nursing is to This information would be useful in de- Applications in Nursing.31 Currently, a survive, it must be able to demonstrate the signing and delivering future services for survey is being developed to collect infor- effectiveness of its services. Economic improvement of public health nursing. mation from those who have requested pressure has resulted in shrunken depart- The applicability of the NMDS to current the NMDS Data Collection Manual.17 ments and a diminution of services in public health nursing concerns, such as Responses to the questionnaire will pro- some settings. A new federal department, the immunization of children, care of the vide information about the NMDS use, the Agency for Health Care Policy and AIDS population, and nursing care of the implementation of the data set, and Research,2-6 28has been created in the of- homeless, is readily apparent. whether the respondents might be inter- fices ofthe Assistant Secretary for Health Public health nurses would be able to ested in planning cooperative or collabo- to study and enhance the effectiveness, evaluate their services, for they would rative research on the NMDS. appropriateness, and quality of care. If have the data to demonstrate what impact Nurses in all functional areas can and nursing information is not included in this a new program has had on diagnoses, in- should find a role for themselves in pro- data base, the need for nursing will not be terventions, and outcomes. And most im- moting, implementing, and testing the demonstrated. Long-term planning and portantly, theywould have a minimum set NMDS in the interest of improving client the use ofresources will be determined by of readily retrievable data that would en- health care. The ANA Resolution32 on what has been demonstrated from these able them to measure outcomes in nursing computerization of nursing services data data. Therefore, if public health nursing terms, in addition to the traditional medi- is still as applicable, and as much needed, (and nursing generally) is to play a major cal indicators of morbidity and mortality. today as it was when it was passed unan-

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426 American Journal of Public Health April 1991, Vol. 81, No. 4